"I Never Hope for Anything...Now I Have Other Plans": The Role of Microfinance in HIV Intervention for Women Who Use Drugs and Engage in Sex Work in Kazakhastan

Background and Purpose: Over the past decade, Kazakhstan experienced increasing incidence of HIV, especially among women who engage in sex work and use drugs. The high risk of HIV acquisition and transmission among female sex workers is exacerbated by the intersection of injection drug use and low condom use. Women who engage in sex work and use drugs experience an array of structural inequalities that limit their access to care, and also increases HIV risk. Research has examined feasibility and efficacy of structural interventions to reduce HIV risk; however, few studies have examined the experiences of women participating in these interventions. This study aimed to understand the perceived impact the intervention components of a combination of HIV risk reduction and microfinance intervention had on women’s sexual and drug risk behaviors as well as their capacity for reducing income from sex work and finding alternative sources of income.

Methods: Data for this study were drawn from the qualitative component of the Nova study, a cluster-Randomized Controlled Trial (c-RCT) conducted from 2014-2019 in Kazakhstan to evaluate the efficacy of a combination HIV risk reduction (HIVRR) and microfinance intervention (HIVRR+MF) among 354 women who engage in sex work and use drugs. The parent study was guided by Social Cognitive and Asset theories. Guided by a narrative approach, fifty-six interviews with 19 participants were conducted. Interview domains included attitudes towards intervention and participation experience. Audiotaped interviews were conducted in Russian, transcribed and translated into English and back translated. The research team conducted two coding cycles and intercoder agreement was established at 75% (Miles & Huberman, 1994). Narratives were analyzed following guidelines suggested by Braun & Clarke (2006).

Findings: Women who received both HIVRR and HIVRR+MF reported increased knowledge and skills related to condom use, safe sex practices, and drug use reduction. Components of the HIVRR that were most helpful were role-playing skills and videos demonstrating the consequences of unprotected sex and drug use. Women who received HIVRR+MF, reported increased control over their budget, savings, and capacity to plan for their future. The vocational component of the HIVRR+MF intervention encouraged women to find alternative sources of income. Women also reported that learning communication skills helped them to decrease interpersonal conflicts and enabled them to increase negotiation of condom use.

Conclusions and Implications: These qualitative findings underscore the significant role that structural interventions play in HIV risk reduction and in facilitating women’s choice to transition from fulltime reliance on sex work income to alternative sources of income, further reducing exposure to HIV/STIs. Giving women the opportunity to voice their experiences regarding attendance at this structural intervention may inform more culturally competent adaptations of the intervention components, the logistics and environment in which the intervention is offered, as well as the interpretation of quantitative findings. The feasibility and benefits of the interventions expressed by participants suggests the importance of continuing to target and refine such innovative efforts to meet the needs of understudied groups such as women who engage in sex work and use drugs.